On September 21, 2020, the Allegheny County (Pennsylvania) Department of Human Services (DHS) began rolling out a “first of its kind” parenting initiative called Hello Baby. The program aims to support and strengthen families of newborns who are at risk of abuse and neglect, so as to prevent the occurrence of maltreatment rather than responding after it occurs. This new program is an innovative approach that attempts to avoid the flaws of many other programs that aim to prevent child maltreatment.
Hello Baby is a “voluntary program for parents of new babies, designed to strengthen families, improve children’s outcomes, and maximize child and family well-being, safety and security.” As described in a Frequently Asked Questions document and a Methodology Report on the Allegheny County Analytics website (which contains. many other relevant documents as well), the program combines a universal entry point with differentiated services in a three-tiered approach, as described below:
- Universal Tier: Services available to all new parents in the county include a “warmline,” the Hello Baby website, and a texting service staffed by volunteers to answer questions about newborns and parenting issues.
- Family Support Tier: Families with “moderate needs” will be served through the existing network of 27 Family Centers located around the county. These families will have access to the rich array of services offered by these centers, including home visiting, family support, and child care subsidies.
- Priority Tier: Families with the most complex needs are offered the support of a two-person team employed by Healthy Start Pittsburgh, which was selected through a Request for Proposals. The teams are made up of a family engagement specialist, who functions as a peer counselor, and a social worker who plays the role of case manager. In the pandemic environment, they will meet with families both virtually and in home visits. These teams work with families to learn about their needs, connect them to resources, and provide wraparound assistance, which will be available until the child turns three years old. This wraparound assistance can include concrete goods, transportation assistance, and connections to community resources. The priority tier model is based on the COACH Model of the Camden Coalition, a behavior change intervention for people with complex needs.
Every new mother in the county receives information about the program through her birthing hospital, OB/GYN, or pediatrician and may receive an initial visit from a nurse to talk about the program in more detail. A few weeks later, each family receives a postcard informing them of the universally available services and giving them the opportunity to opt out of further contact. Families with moderate and higher levels of need who have not opted out of services will be contacted by the Family Centers or two-person teams, respectively.
The placement of newborns into three different risk groups will be based on a predictive risk model (PRM), another unique part of this program. The model is designed to identify the families with the highest likelihood of having a child removed to foster care before the age of three. The model uses data already available from birth records, child protective services, homeless services, and justice system records to calculate a risk level for each child. Model development was led by Rhema Vaithianathan and Emily Putnam-Hornstein, along with the data science team based at the Centre for Social Data Analytics (Auckland University of Technology, NZ). Vaithianathan and Putnam-Hornstein are world leaders on the use of PRM in child welfare, and they have been working with Allegheny DHS since developing the county’s child abuse hotline screening tool in 2015. While most Priority Tier slots will be filled through PRM, some slots will be reserved for parents who request intensive support or those referred by clinical providers.
The program planners made extensive efforts to address potential concerns about privacy, coercion to participate, or involvement with child protective services (CPS). Hello Baby is not connected to CPS. The risk scores will not be shared beyond program staff, used after the initial screening, kept on file, or used for any child welfare purpose. No family will be reported to CPS for refusing to participate in the program. DHS estimates that 40 percent of the families assigned to the most intensive service tier will already be involved with child welfare. These families will be eligible for the program except when safety issues are so grave that the baby is removed right after birth by CPS. If the family agrees, Hello Baby staff can work directly with the child welfare caseworker to make sure the family receives the best services to meet their needs.
The FAQ document cites several reasons for the development of Hello Baby. For one, agency leaders recognized that the county was rich in programmatic resources but that the resources were not reaching those who needed them both. Second, they realized that the historical practice of targeting high-poverty areas for prevention efforts (like the county’s Family Centers) leaves out many families in need because the root causes of child maltreatment (such as substance abuse, mental illness and intimate partner violence) cut across economic lines. Finally, even within a community with a Family Center, evidence suggests that those who need it most may not access the services.
The focus on ages 0 to 3 was chosen because infants and children are most at risk of serious abuse and neglect–and most likely to die of such maltreatment. Almost 80 percent of Allegheny County children who suffered fatalities connected with abuse or neglect were under the age of three. And half of them were unknown to the child welfare system, which means that there had been no earlier opportunity to protect the child.
According to an account on the county’s DHS website, Allegheny’s child welfare leaders began thinking about a child maltreatment prevention program using a tiered approach supported by predictive risk modeling (PRM) in 2015, when they were developing the Allegheny Family Screening Tool (AFST) for screening hotline calls to determine their relative risk level. If they could use PRM to screen child maltreatment reports, DHS leaders asked, would there be a way for them to use these methods to reach families “BEFORE they reach the breaking point?”
The fact that Allegheny County DHS is already using PRM to screen hotline calls is a testament to the vision and courage of its leadership. Few other jurisdictions have implemented PRM in child welfare in part because of the controversy surrounding the use of an algorithm in decisions about case opening. But DHS Director Marc Cherna is one of the longest-serving human services directors, having served in the position since 1997 and has won nationwide recognition for his innovative initiatives. He was was the first director of DHS, a mega-agency that was the outcome of a merger between several discrete departments. As described in a case study, Cherna took the opportunity to create a “data warehouse” integrating information from the formerly separate agencies. This integrated database in turn provided the opportunity to improve decision-making using PRM. In response to a Request for Proposals, DHS chose the team led by Vaithianathan and Putnam-Hornstein to develop the AFST and later the Hello Baby tool as well.
Hello Baby is the outcome of many years of research and planning by DHS leadership working together with community members, according to the FAQ document. The process included an extensive literature review focused on how to engage and retain families with intensive and complex needs. In addition to the internal literature review, DHS commissioned two independent ethical reviews. The developers also met with families receiving services, service providers, clinical experts, judges, Family Court advocates, peer support agencies, national experts, local funders; and civil liberties, civil rights and social justice organizations to identify service gaps and concerns. Finally they conducted case reviews with social workers and child development experts in order to understand the population they were seeking to reach.
Hello Baby was launched on September 1, 2020 and is being piloted at a subset of sites before being rolled out statewide after a year. DHS anticipates providing Priority Tier service to five percent of families with new babies or about 650 families per year when the program is fully implemented. The County has contracted with two respected social science research institutes–Chapin Hall and the Urban Institute–to conduct process and impact evaluations of Hello Baby.
As Vaithianathan and Putnam-Hornstein explain in their methodology document, we know very little about what works, and for whom, to prevent child maltreatment. Therefore, new approaches are needed. Hello Baby’s combination of universality and targeting is appealing based on logic. As DHS. explains in an implementation brief provided to Child Welfare Monitor, universal services have many benefits, like reduced stigma, wider reach and no need for eligibility requirements. But when resources are limited, services are stretched thinly across many families. Families with the greatest needs may not get the intensity of services they need, while families with lesser needs may receive support disproportionate to their needs. Hello Baby addresses this problem with its tiered service array.
DHS has undertaken an elaborate process to protect privacy and self-determination and prevent the use of risk scores in any context other than assigning families to Hello Baby tiers. However it must be recognized that there is a tradeoff between parental self-determination and protecting children. Prior research indicates that it is difficult to engage the highest-risk families in voluntary services. By ruling out the possibility of reporting these families to CPS, DHS may be condemning some children to years of neglect, abuse, injury, or even death. We hope that DHS will collect and report on the number, risk scores, and future maltreatment reports, of those who decline to participate in order to assess the extent of this problem.
We congratulate Allegheny County for the implementation of Hello Baby. The lack of attention to the rollout by prominent child welfare organizations, thought leaders and media is surprising. We hope that child welfare leaders are are paying attention to this important initiative and thinking about options for similar programs.
: Much of the controversy around PRM centers on fears that it will exacerbate racial disparities in child welfare decision making. But an evaluation of the AFST has suggested that it has reduced, rather than increased, racial disparities in the rate of case opening between White and Black children, thus assuaging fears that it would increase such disparities.